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Anaesthesia 1000 Years Ago (I)

The following research article in a particular field of the history of medicine, written by two eminent experts, Drs Adnan A. Al-Mazrooa and Rabie E. Abdel-Halim, is composed of two parts. This first part surveys the use of narcotics for pain relief from Antiquity up to the Renaissance; the second part is a historical investigation in the contribution of the Islamic medical tradition to develop anaesthesia methods and uses. Reviewing some of the medical texts written by Muslim scholars from the 9th to the 14th century, the authors present evidence that anaesthesia monitoring and resuscitation were practised by Muslim scientists more than 1000 years ago.

Pain is a subjective experience which requires the presence of consciousness. Over the ages there has been a demand for methods of relief. In the following sections, we present a brief report about the use of narcotics for pain relief from antiquity up to the Renaissance, in Greek and Roman medicine and in the Middle Ages, before turning to analyse the anaesthesia in the Islamic medical tradition.

Figure 1: Drawing of the cross section of the Brain and the Eyes made by the 13th century Khalifa ibn Abi Al Mahasin Al-Halabi (from Aleppo) in his book Al-Kafi Fi Al-Kuhl (The Book of Sufficient Knowledge in Ophthalmology) (Source).

Though Celsus [1], in the 1st Century, used opium and mandrake for pain relief, Galen in the 2nd century (as stated by Cumston [2] and De Moulin) recommended great care with the use of powerful narcotics such as opium, considering it a dangerous drug. According to Campbell [4] and Cumston [2], Galen was looked upon as one of the great physicians. He summarized the knowledge accumulated in Greek medicine up to his time and studied every aspect of medicine. In cases of colic or other very violent pains, he used only opium.

After Galen, Greek medicine produced four writers who did not contribute any advancement. Their works mainly consisted of quotations from Hippocrates and Galen [4]. As a consequence, the strong narcotic drug mandrake used by Celsus [1] seems to have fallen into neglect; confirmation of this is that Paulus [5] in the 7th Century, who is regarded as having summed up all medical knowledge accumulated up to his time, did not use it in his trochisci as an anodyne.

Paulus did not give the toxic dose or details of the specific actions of either mandrake or opium. It seems that there was no standardization or regulation of dosage [6][7]. It was therefore impossible to standardize the results [6][8][9] and, attempts at the conquest of pain were sporadic [10].

Figure 2: The prologue page of a manuscript of Kitab Al-Mansuri Fi Al-Tib written by Muhammad Ibn Zakariya Al-Razi (Source).

In the Middle Ages, Christian Europe was in a state of intellectual stagnation [2][4][7][11][12] and the theological doctrine that pain serves God's purpose and must not be alleviated militated against the improvement in methods of narcosis. Nuland [7] points out that the Middle Ages in Europe were dark ages so far as advances in the pharmacology of anaesthesia was concerned. However in the East, with the firm establishment of the Muslim supremacy between the 9th and 16th centuries, the study of medicine along with other branches of science revived and acquired a truly scientific nature [2][4][13][14][15].

Therefore, not only Ibn Sina (Avicenna) [16] but also Al-Razi [17], Al-Baghdadi [18] and Ibn al-Quff [19], paid great attention to the phenomenon of pain. They attributed it not only to a breach of continuity, as stated by Galen, but also to a sudden change of temperament (by only heat, cold or dryness) with or without abnormal humours. Hence, for pain relief, they stressed the treatment of the underlying cause and they subsequently developed a large number of analgesics with variable modes of action. The anaesthetics they described included a wide range of medical plants as well as ice or very cold iced water as an efficient and safe mode of local anaesthesia even though there might be an increase in the pain at the beginning. Refrigeration anaesthesia which is considered by some to be a modern discovery, thus, had its origin in the medicine of the past.

They attributed the anaesthetic action of the various medical plants used to a specific poisonous property of variable strength, and thus according to Ibn Sina (Avicenna) [16], opium is the most powerful, then mandrake, papaveris, henbane or hyocyamus, hemlock, solanum and wild lettuce. These drugs, especially opium, were used as local anaesthetics in dental cases, earache, eye pain and joint pain (especially in gout).

In dentistry, they used opium, mandrake root or henbane juice in the form of pastes, patches or fillings. Gargles from decoctions of mandrake root, henbane root or seeds or the root of solanum were also used.

Opium drops in rose oil, infusion of root of solanum, decoction of papaveris, oil or juice of henbane and angelica juice were used for earache. The relief of eye pains was achieved by either using dressings from mandrake leaves or mixing the eye medicines with mandrake tears or juice of hemlock. Embrocations of the juice of henbane leaves or seeds were also used on the eye and, for joint pains, dressings from mandrake leaves or embrocations from opium, hemlock, henbane or cannabis.

In addition, because it was noticed that severe pain may lead to death, the soporific action of these drugs was employed especially pre-operatively in the cases of amputation, cautery, circumcision and lacerations. They were administered by ingestion, inhalation or rectally. Infusions of solanum, cannabis, opium and mandrake were given orally or rectally on a plug which has to be changed hourly. Opium, mandrake and henbane were also used by inhalation in the form of odorants.

The wild lettuce has a mild soporific effect. It was used either fresh or boiled as an adjuvant to any of the previous medications or alone in cases of insomnia.

These physicians not only determined the required dose in each drug precisely but also were able to fix the length of time which the anaesthesia was to last with great precision. Avicenna for example, gave the dose of one 'mithkal' of mandrake for 3-4 hours of general anaesthesia.

Unlike Paulus [5], Ibn Sina [16], AI-Razi [17], Al-Baghdadi [18], Ibn EI-Quff [19] and Ibn al-Baytar [20] in the light of their own experiments and observations, described the general and special botanical characters of the plants in detail as well as indicating their habitats and what was best selected from each. They also specified methods for obtaining the active ingredients whether as juice or in the various medical forms that can be prepared as infusions, decoctions or dressings.

They also described the specific actions and side effects on the various systems of the body and stated with great accuracy the required dosage from juice, bark or decoctions as well as the toxic dose. Finally, they outlined the action of antidotes, adjuvants and alternative remedies.

The Muslims must be given the credit for developing the science of botany [12][13][21]. Ibn al-Baytar is one of the greatest Arabian botanists [2][20][22][23]. His book Al-Gami' Al-Kabir is the most original among the Arabic materia medica texts of the mediaeval period. Arabic materia medica had a considerable impact on European herbal and antidotarium authors from the 12th to the 17th century [2][4][24][25]. Constantine wrote nothing original; all his books are plagiarisms or skilfully disguised translations from the Arabic. The medicinal remedies reported by Dioscorides are thus of Islamic origin [2]. The same may be said of the work of Celsus which was hardly noticed by the Greeks and overlooked in the Middle Ages [26]. In the section on emollients (vol. 2), Celsus describes one of them as the invention of a certain Arab, and some of his recipes are based on Arabic materia medica with its tables of weights and measures (pound, dirham and dinarium or dinarii).

The only conclusion possible is that the writings of the Muslim scholars in their Latin form influenced European medical thought over a very considerable period.